Title: Establishing the Quality of Surgical Care among VA Patients with Kidney Cancer Background: The Veterans Health Administration (VHA) has been at the forefront of the improvement of care given to its patients. These efforts have resulted in the development of measures, or quality indicators (QI), that provide important data needed to identify gaps in care and prioritize policy, educational and funding initiatives in order to optimize health care efficiency. However, a paucity of literature exists capturing real-world data validating these indicators as benchmarking tools that can accurately identify providers delivering poor care on a national level. Within urologic oncology (e.g. kidney cancer), several QIs have been proposed but few are based on high-level scientific evidence. Furthermore, none have been validated on a large scale in general clinical practice against hard outcomes (e.g. survival). Aims: In this pilot proposal, we aim to determine the real-world benchmarking performance (feasibility) and validity of QIs proposed in the literature and by expert consensus panels in kidney cancer. 1) Determine the feasibility of measuring data for each QI from the VA Informatics and Computing Infrastructure (VINCI), Corporate Data Warehouse (CDW), and VA Cancer Registry (VACCR). 2) Capture quality variations via benchmarking hospital-level performance for each QI by developing risk-adjusted models for each QI. 3) Determine the impact of quality variation on patient outcomes. 4) Determine structural factors (i.e. hospital volume and location) associated with improved quality. Relevance to Veteran?s Health: The proposed study will allow for the objective assessment of quality of care in the treatment of kidney cancer, and potentially to other malignancies in the future. This will allow for improved care among veterans by providing feedback to providers and the possible creation of specialized centers for complex cancer care. Innovation: This will be the first study providing a validated set of QIs suitable for benchmarking kidney cancer care using population-level data within the VHA. Methodology: We will use data from VINCI, CDW and VACCR to identify proposed QIs among incident cases of kidney cancer from 2005-2015. QIs will be adjusted for case-mix using indirect standardization, where for each hospital a standardized mortality ratio of observed to expected outcomes (SMR=O/E) will be calculated. To identify hospitals performing better or worse than expected (i.e. outlier) for a given QI, p-values will be calculated for tests of the hypothesis SMR=1, with p-values being obtained from exact binomial tests. Finally, patients treated in good or poor outlier hospitals will be compared with patients from non-outlier hospitals in terms of their outcomes, including treatment-related complications, in-hospital morbidity, length of hospital stay, re-admission rate, as well as mortality. Expected Results: The completion of this proposal will yield VA validated benchmarking tools that can be utilized by policy-makers, hospitals and providers to measure the quality of urological cancer care delivery within VHA and other Healthcare systems nationally.